Edgerton Hospital violated policies
EDGERTON — Edgerton Hospital plans a slew of corrective actions in the wake of an investigation that showed the hospital was understaffed on several days this year.
Investigators from the state Department of Health and Human Services found that the hospital did not follow its own policies for staffing nurses during more than a dozen night shifts and that hospital staff did not properly report the details of an "unexpected" cardiac emergency in August that left a patient dead, according to a state report.
The violations surfaced after an anonymous complaint that the hospital had left its emergency room without staff for nearly an hour overnight Aug. 9 while patients were there, the report said.
According to the report, the incident happened early Aug. 9, while hospital staff was responding to an inpatient and a nurse who were both suffering apparent cardiac emergencies at the same time in another part of the hospital.
The inpatient, who is not identified by name, reportedly died later Aug 9.
Investigators learned that the hospital had staffed enough nurses for the night shift Aug. 9. But the investigation revealed that the hospital was short-staffed on 29 other days between March 12, 2012, and September 24, 2012.
Those findings put the hospital under "immediate jeopardy" by the Department of Health and Human Services and the federal Centers For Medicare and Medicaid Services, which was also involved in the investigation.
"Immediate jeopardy" is applied when violations are shown to seriously endanger patients. It can result in the loss of Medicare and Medicaid funding, according to officials.
The report indicates the hospital is now in compliance with its own rules.
According to the report, the hospital also had allowed cardiac and respiratory emergency response training for some nurses to lapse for months, and staff had at times turned the volume down or off on the hospital's 911 emergency scanner, according to paramedics who were interviewed.
The report also disclosed that staff had not immediately reported details of the nurse's medical emergency Aug. 9 to the hospital's board of trustees—protocol required by hospital policy, officials said.
The Aug. 9 violations occurred because staff had been pulled from the emergency room to deal with a pneumonia inpatient and a nurse who were having medical emergencies nearby in the swing bed area of the hospital, said Steve Van Dinter, a spokesman for SSM Health Care, which is affiliated with Edgerton Hospital.
That left the emergency room without staff for nearly an hour while two patients, including one with a head injury, waited there for test results, according to the report.
"It's a once-in-a-lifetime occurrence. It's a rare situation, but nonetheless it happened," Van Dinter said.
According to reports, the nurse was caring for the pneumonia patient when she fell over in the patient's room and stopped breathing. Staff carried the nurse to another room while other staff gave the patient resuscitation. Then staff gave the nurse resuscitation, the report said.
There are no records of staff calling off-duty staff for extra help during the incident.
The Gazette could not immediately obtain Rock County coroner's records from Aug. 9, and Edgerton Hospital and the Department of Health and Human Services could not immediately confirm the status of the hospital nurse or supply a copy of the complaint from Aug. 9.
Hospital policy requires at least two registered nurses on call when the hospital has 10 inpatients and three nurses with 12 or more inpatients, said Van Dinter and Edgerton Hospital Quality Director Elizabeth Luchsinger.
Luchsinger and Van Dinter said the policy is more stringent than state and federal mandates for hospitals of Edgerton's size.
Van Dinter said chronic understaffing happened in part because supervisors had been lax on staffing at times when inpatient counts were low and patients' conditions were not severe.
He said the hospital now plans to stick to staffing based on the number of patients at the hospital, not the "complexity" of their illnesses.
Luchsinger said the hospital uses an alert system that can send automatic emergency pages to on- or off-duty staff through phone calls, emails and text messages. The system was not in use before the investigation, Van Dinter said.
The hospital also has a new policy to ensure its nurses stay up to speed with training and notify the board of trustees of serious emergencies involving patients and employees, Luchsinger said.
Van Dinter said staff had not immediately told the board about the nurse's Aug. 9 health emergency because of privacy concerns.
